The present invention is directed to an effective drug delivery vehicle involving the containment of a therapeutic agent within a hydrogel, which hydrogel is then bound to a substrate. The substrates of the present invention include any in-dwelling medical device or implant, wound dressings, wound closures, and the like. The present invention further provides means for compounding such hydrogels and affixing such hydrogels to a substrate.
The control of infection acquired in a clinical setting is a major and significant health care problem. Infections contracted during patient treatment within healthcare facilities have been estimated to contribute to ninety-thousand (90,000) deaths and cost $12 Billion dollars U.S. to treat per annum.
Nosocomial bacteriuria is the most common infection contracted in long-term care facilities and is usually associated with catheterization. The condition is virtually universal in patients after thirty days of catheterization. Complications will include fever, acute and chronic pyelonephritis, bacteremia and renal stones. The extra-lumenal surface of the catheter may become colonized with bacteria and act as a conduit for bacterial entry into the bladder. The best preventative measure is to limit the use of long-term in-dwelling catheters; this is often not possible. J. W. Ward, xe2x80x9cManagement of patients in long-term care facilities with catheter-associated bacteriuriaxe2x80x9d Infect.Urol. 9, 147-152 (1996). However, all patients will develop bacteriuria if catheterized for a long enough period.
Catheter-related septicemia occurs in approximately 400,000 of the estimated five million Americans who are catheterized each year. Treatment for a single event of catheter-related septicemia in a critically ill patient adds approximately 6.5 days to a stay in an intensive care unit and will cost about $29,000. I. R. Raad and R. O. Darouchie, xe2x80x9cCatheter-related septicemia: risk reduction.xe2x80x9d Infect Med 13:807-812, 815-816, 823 (1996). Indeed, catheter-related septicemia represents the most common life-threatening complication associated with intravascular catheters. There is a strong relationship between catheter-site inflammation and the recovery of bacteria from the surface of the device. In situ, the catheter surface becomes colonized with opportunistic microbial pathogens, and these colonies become the source of infections.
A common source for catheter colonization and catheter-related sepsis is the skin insertion site. Indeed, the skin surface is the most common source of short-term catheter colonization and subsequent infection. Catheter-related infections remain a significant problem in healthcare facilities. It is generally accepted that no method has yet emerged for the adequate and satisfactory management of catheter-related infection.
The adhesion of microorganisms to the catheter surface is related to the interaction of the host, the microorganisms and the catheter material. The host tissue reacts to the catheter material as a foreign body and deposits a thrombin coat over the material, which becomes colonized with microbes, often within 24 hours; this coating of protein and microorganisms is called a biofilm. In the biofilm, microbes find a suitable niche for continued growth as well as for protection from antibiotics, phagocytic neutrophils, macrophages and antibodies.
There have been numerous attempts to produce biomedical products that impede or prevent infection. Biomedical products that incorporate and release silver compounds for infection control have been studied for many years. However, clinical studies of these products, including catheters, have shown only minor improvements in infection control. The devices have been described to exhibit resistance to infection, but in practical application fail to adequately inhibit infection.
Ciresi et al. 1996 (Am Surg 62:641-646) compared the incidence of catheter-related infection and catheter-related sepsis between a standard catheter and the recently released Arrowgard.TM. catheter in a clinical trial with one-hundred-ninety-one patients receiving total parenteral nutrition. The Arowgard(trademark) catheter contains a combination of silver sulfadiazine and chlorhexidine, that is thought to render the catheter surface resistant to bacterial colonization and subsequent sepsis. The authors concluded that the coating of the central venous catheters with sulfadiazine and chlorhexidine does not reduce the rate of catheter-related infection or catheter-sepsis when compared with a standard central venous catheter in patients receiving total parenteral nutrition.
Hasaniya et al. 1996 (Chest 109:1030-1032) found that the use of an attachable subcutaneous silver-impregnated cuff failed to decrease the incidence of central venous catheter-related infection and sepsis.
In U.S. Pat. No. 4,442,133 there is disclosed a process for vascular prostheses with a cationic surfactant, e.g. tridodecylmethyl-ammonium chloride (TDMAC), to increase sites for antibiotic bonding. Before the prostheses are used they are dipped or coated in a solution of TDMAC to adsorb the antibiotic.
Stickler et al. 1994 (Cells and Materials 4:387-398), conclude that pretreatment by adventitious coating of catheters with ciprofloxacin (an antibiotic) is unlikely to prevent bacterial biofilm formation on long-term, in-dwelling silicone or silicone-coated latex urethral catheters.
U.S. Pat. No. 4,749,585 provides a method for coating a prosthesis with an ionically charged surfactant and an antibiotic compound encapsulated within phospholipid vesicles, wherein said vesicles have a surface charge opposite to that of said surfactant. The drawback of this system is that the amount of liposomes coated on to the surface is generally low, not allowing for a therapeutic dose of drug to be retained on the device for periods of time necessary to suppress or alleviate the infection. Second, upon insertion of a device, such as a catheter so treated, it is expected that the surface coating of ionically bound liposomes will be sheared off from the area where the liposomes were intended to reside.
Oloffs et al. 1994; Biomaterials 15:753-758, describe the biocompatibility of silver-coated polyurethane catheters and silver coated Dacron(trademark) material to inhibit infection. These fail to inhibit catheter-related bacterial infection at the infection site (vide supra).
Schierholz, J. et al. 1994; Biomaterials 15:996-1000, disclose the incorporation of antibiotic into an antibiotic releasing silicone ventricle catheter to prevent shunt infection. The antibiotic (rifampicin) was added to the swelling-activated polydimethylsiloxane matrix and would diffuse from the matrix.
Wachol-Drewek et al. 1996, Biomaterials 17:1733-1738, disclose the use of collagen implants of various structures and a gelatin sponge which were placed in antibiotic solutions and allowed to absorb the compounds. They concluded: xe2x80x9cIf an implant that has a protective effect against wound infections over a period of 24-48 h is required, the materials described here are suitable. However, where treatment in infected areas should ensure antibiotic cover for 5-10 d[days] neither collagen materials immersed in antibiotics nor collagen sponges containing gentamicin are suitable.xe2x80x9d
Several studies have used photoactivated surface modification in attempts to improve the biocompatibility of biomedical devices. The synthesis of phenylazido-derivatized substances and photochemical surface immobilization of functional groups is presented by Sugawara and Matsuda (J. Biomed Mater Res 32:157-164).
The surface modification of silicone by corona discharge for the immobilization of various proteins is disclosed by Okada et al. 1987 (Biomaterials and Clinical Applications, pp. 465-470, Pizzoferrato, A., Marchetti, P. G., Ravglioli, A., and Lee, A. J. C. Elsevier Scientific Publishers, Amsterdam).
Photoreactive surface modification of fabricated devices is described in Matsuda and Inoue 1990 (Trans Am Soc Artif Intern Organs, Poster Session 1, Biomaterials, pp. M161-M164). Nakayama and Matsuda 1992 (ASAIO Journal 38:M421-424) describe the incorporation of heparin, useful as a thromboresistant molecule, within a hydrophilic co-polymer of poly(N,N-dimethylacrylamide)-poly(2-cinnamoylethyl methacrylate) linked to a polyethylene terephthalate surface using a photochemical process; poly(m-azidostyrene) was initially applied to the polyethylene terephalate surface to provide a reactive interface. The procedure produces a cross-linked matrix in which heparin is retained. Sigrist et al. (Optical Eng. (1995) 34:2339-2347) describe surface immobilization of biomolecules by light. Aldenhoff and Koole (J. Biomed. Mate. Res. (1995) 29:917-928) describe a method for the photoimmobilization of protein to polyurethane surfaces.
The clinical problem remains that the catheter-related biofilm mediated infection can only be adequately treated by surgical intervention and removal of the bacterial-laden device followed with antibiotic therapy, and surgical re-insertion of a new medical device at a later date. The discomfort to patients and the high costs of these procedures are evident.
The treatment of biofilm-mediated infection on the surface of medical devices is currently extremely difficult, and no medical device or remedy presently available adequately manages liquid-flow conduit line-related infection. Therefore, there is an urgent need for a method of providing adequate doses of antibiotic consistently in targeted fashion on the surface of in-dwelling medical devices so that bacteria are unable to establish a biofilm during the first five to ten, or more days after insertion of the medical device or application of dressings, suture, pins, clips, and other medical devices. There remains a need to develop a practical method for deterring microbial biofilm development on the surface of catheters and other in-dwelling medical devices in contact with tissue, so that device-related infections are significantly reduced.
It is an object of the present invention to provide a biocompatible hydrogel matrix, containing liposomal antibiotic that can be coated onto the surface of in-dwelling biomedical devices. It is a further objective to provide methods for formulating such hydrogel matrix compositions; and it is a still further objective to provide methods to co-valently attach said hydrogel to the surface of substrates such as catheters. The type of drug incorporated into the hydrogel formulation is not restricted to any single antibiotic, or combination of one or more of these. Similarly, the hydrogel composition might comprise a variety of active agents including antibiotics, hormones, growth factors and other factors that are beneficial for the condition under management, in accordance with sound medical judgement.
The present invention avails the use of antibiotic-loaded liposomes sequestered within a biocompatible hydrogel retained on the surface of the biomedical device, e.g. catheter. Liposomes, microspheres, nanospheres, biodegradable polymers, and other systems are excellent drug delivery vehicles; and the methods of preparation and drug loading procedures for liposomes and the others are well-known in the art. Liposomes can store both apolar and polar compounds via interactions with the biocompatible and biodegradable lipid bilayer, or compartmentation within the aqueous core, respectively.
A method for producing a biofilm-resistant surface might involve the binding of antibiotic-containing liposomes directly to the surface. Theoretical calculations however, indicate that if a surface was saturated with drug-carrying liposomes, only about 150 ng of the antibiotic ciprofloxacin could be localized per square centimeter of surface. Nanogram quantities of ciprofloxacin are unlikely to provide protection from microbes over substantial periods of time, e.g. several days or more. We have devised a means to effectively exploit the space above the catheter""s surface to significantly increase the surface area concentration of bound liposomal antibiotic. Specific formulation of the liposome bilayer allows for drug release over a period ranging from days to weeks. See, e.g., R. Nicholov, V. DiTizio, and F. DiCosmo, xe2x80x9cInteraction of paclitaxel with phospholipid bilayers,xe2x80x9d J. Lipo. Res., 5, 503-522 (1995). M. S. Webb, T. 0. Harasym, D. Masin, M. B. Bally, and L. D. Mayer, xe2x80x9cSphingomyelin-cholesterol liposomes significantly enhance the pharmokinetic and therapeutic properties of vincristine in murine and human tumour models,xe2x80x9d Br. J. Cancer, 72, 896-904 (1995). Furthermore, the biocompatibility of liposomes ensures that they will be safely degraded and assimilated by the host after their supply of drug is exhausted after six days or more.
The method of the present invention provides for co-valently attaching liposomes to a substrate such as a catheter, or other liquid-flow conduit, or other device, such as a wound dressing. The method exploits the surface area of the device as well as the volume occupied by the hydrogel matrix bonded to the surface. The volume of gel matrix can accommodate large quantities of drug-loaded liposomes, microspheres, nanospheres, or other drug carrier and consequently, relatively high doses of a therapeutic drug can be deposited at specific sites. The hydrogel matrix is biocompatible and biodegradable (i.e. does not release potentially toxic degradation products), and will ensure protection of the liposomes from membrane-disrupting shear forces that are encountered during handling and insertion of the device, and from rapid degradation of the liposome in vivo. The containment of the liposomes within the gel matrix also creates an opportunity to control drug diffusion rates, thereby affording long-term drug efflux.
Thus, the present invention includes a method for loading efficacious quantities of a liposomal therapeutic agent on a medical device by mixing said liposomal therapeutic agent with a hydrogel, and covalently binding said hydrogel to a preformed polymeric surface of a medical device. By pre-formed polymeric surface is meant that the polymeric material used in fabricating the medical device is formed or manufactured in advance of the covalent attachment of the hydrogel. As discussed more fully below, covalent attachment of the hydrogel to the polymeric material can be effected through the use of a bifunctional linker molecule, preferably one comprising an azide functional group. Preferably, the pre-formed polymeric surface is a silicone rubber.
One such embodiment is a silicone catheter loaded with a co-valently bonded polyethylene glycol-gelatin matrix containing a liposomal antibiotic-carrier coating to control catheter-related infections, such as bacteriuria and septicemia. Medical devices where the coating can be used include catheters, wound closures, surgical dressings, temporary orthopedic implants and others.
The liposomal hydrogel of the present invention includes a variety of hydrogel drug combinations. Generally, the selection or pairing of the hydrogel and drug is determined only by the desired application and relevant indication. That is, any active agent that can be compounded into liposomes, microspheres, nanospheres, or other suitable encapsulation vehicle can be confined within the hydrogel matrices of the present invention to create the therapeutic hydrogels of the present invention. Those hydrogels can then be affixed to a substrate such as the surface of a catheter or other in-dwelling liquid conduit, or the substrate or matrix of a wound closure or wound dressing material.
One embodiment of the present invention involves the deposition and co-valent attachment of a polyethylene glycol-gelatin matrix layer to the surface of in-dwelling biomedical implants (e.g. catheters, stents, intravenous tubes, dialysis tubes, orthopedic implants, surgical sponges and wound dressings, etc.) and the sequestration or covalent attachment of liposomes to the constituents of the matrix. The liposomes contain a therapeutic. The matrix thus constitutes a vehicle for the containment of high concentrations of therapeutic agent such as one or more antibiotics, hormones, steroids, growth factors, antihistamines, colony stimulating factors, interleukins, and the like, and/or combinations thereof. The therapeutic hydrogels of the present invention can be used in the management of tissue and biomaterial associated infection. The matrix can be a hydrogel (e.g., gelatin, pectin, etc.), a protein (e.g. collagen, hemoglobin, etc.), or other adjuvant. Preferably, the matrix will have some structural integrity as by cross-linking or similar structural support to impart resistance to shear forces resulting from insertion of the device.
Thus, the present invention provides a medical device having a polymeric substrate; a matrix material covalently bound to said substrate; and a liposomal therapeutic agent confined within said matrix material. The matrix material can be a hydrogel, a protein, or other suitable adjuvant. The matrix material will preferably be a cross-linked material. One example is gelatin cross-linked with polyethylene glycol as by reacting gelatin with bis-(amine)-PEG.
Matrix material can be covalently bound to a substrate by a variety of means. For example, a protein such as gelatin can be derivatized with a bifunctional linker molecule such as 4-azido-2,3,5,6-tetrafluorobenzoic acid. That is, the carbonyl carbon of the benzoic acid group can be made to react with a free amine of a protein to form an amide; the azido functionality can be made to react with a methylene carbon of the silicone rubber. In this manner, the matrix material is covalently bonded to the substrate.
The therapeutic hydrogels of the present invention serve as support material for a variety of liposomal therapeutics. Any therapeutic agent suitable for encapsulation in a liposome, microsphere, nanosphere or the like can be utilized in the present invention. For example, therapeutic agents useful in the present invention include antibiotics, antihistamines, hormones, steroids, therapeutic proteins, and the like.
It will be appreciated by those of ordinary skill in the art that the desired concentration of active agent within a hydrogel loaded on a substrate will vary depending upon the characteristics of the chosen active agent. For example, as between an antibiotic and a therapeutic protein, the required concentration of antibiotic, which are generally active in the microgram range, will likely be higher than the concentration of a therapeutic protein, many of which are active in the nanogram range. Other standard dosing criteria will also be considered in selecting the concentration ranges of active agent loaded onto the substrate in accordance with standard practice in the art.
A preferred embodiment of the present invention is a gelatin hydrogel cross-linked with polyethylene glycol (PEG); and dispersed within the hydrogel is a liposomal antibiotic such as ciprofloxacin. Ciprofloxacin has been shown to exhibit good activity against a broad spectrum of bacteria, particularly those associated with urinary tract infections.
Such embodiments provide dramatically improved in-dwelling medical devices. Medical devices of the present invention can be loaded with as much as 1000 xcexcg/cm2 ciprofloxacin. Preferred embodiments have about 10-300 xcexcg/cm2 ; and still more preferred embodiments have about 25-200 .xcexcg/cm. Thus, the present invention avails long-term, slow release of an anti-infective active agent from an in-dwelling medical device; and dramatically reduces the frequency with which such in-dwelling medical devices must be removed and replaced.
The PEG-gelatin-liposome mixture can be effectively applied to the surface of a silicone Foley catheter that has been pre-treated with phenylazido-modified gelatin. Methods for immobilization of photoreactive gelatin on the catheter""s surface are presented herein. Use of silicone devices is not a limiting feature, as any such polymeric device can be treated to harbor a hydrogel in which liposomes, or other drug carriers are sequestered.
More specifically, the present invention provides a method for associating substantial quantities of antibiotic-releasing liposomes with a silicone Foley catheter through their inclusion in a surface-coating of PEG-gelatin hydrogel covalently linked to the silicone surface, and the antibiotic was released to the surrounding area over a period of greater than five days. Modifications of the technique should allow it to be applied to other medical devices as well, such as, intraperitoneal catheters, joint and vascular prostheses, and reconstructive implants. An attractive feature of this system is the possibility of sustained release of compounds having a range of chemical properties, such as antibiotics, enzymes, growth factors, human hormones, anticoagulants, etc. Also, the surface characteristics of the PEG-gelatin hydrogel will improve biocompatibility of the device as hydrogel-coated catheters tend to minimize the inflammation associated with the presence of any foreign object in the body. J. N. Nacey and B. Delahunt, xe2x80x9cToxicity study of first and second generation hydrogel-coated latex urinary catheters,xe2x80x9d Br. J. Urol, 67:314-316 (1991). The inclusion of gelatin in our hydrogel system will lead to its eventual degradation in vivo leaving a co-valently-bonded surface layer of AFB-gelatin that should be relatively resistant to further protease digestion. T. Okada and Y. Ikada, xe2x80x9cIn vitro and in vivo digestion of collagen covalently immobilized onto the silicone surface,xe2x80x9d J. Biomed. Mater. Res., 26:1569-1581 (1992). It is possible that the remaining layers of gelatin will facilitate better integration of the catheter with the surrounding tissue.
The liposomal matrix materials of the present invention can be used to prevent or treat patients at risk of or suffering from biofilm mediated infection or other forms of infection associated with in-dwelling medical devices, wound closures, and the like. The method comprises inserting into a patient a medical device of the present invention, said medical device comprising a substrate, as for example, a silicone rubber substrate, and covalently bound to said substrate is a hydrogel within which is dispersed a liposomal therapeutic material such as an antibiotic. Likewise, the method comprises replacing infected medical devices with the medical devices of the present invention.
Definitions
By hydrogel or gel is meant any material forming, to various degrees, a jelly-like product when suspended in a solvent, typically water or polar solvents. These gels can be proteins such as collagen or hemoglobin, or more conventional hydrogels such as gelatin, pectin, and fractions and derivatives thereof.
By liposomal therapeutic agents is meant any physical structure surrounding or encapsulating a therapeutic agent such as a drug. Thus, liposomal therapeutic agents will include various drugs or biologically active agents such as antibiotics, antihistamines, hormones, steroids, growth factors, colony stimulating factors, interleukins, and the like confined or encapsulated within a structure such as a liposome, whether of unilamellar or bilayer structure, or microspheres or nanospheres or the like.
A bifunctional linker molecule is any molecule possessed of at least two functional groups that can chemically react with and form covalent bonds with other functional groups or chemical substituents such as the free amines of proteins and the like. Preferably, the bifunctional linker will have an aryl amine functionality, as in an aroyl azide group, and a carbonyl functionality, as in a carboxylic acid group.